Das Konzept der Adherence Einführung in das Thema Prof. Dr. med. Norbert Schmacke Fachtagung Adherence (AOK-BV, Ärztekammer Berlin, AOK Berlin) Berlin, 11.12.2009
Begrifflichkeiten Compliance The extent to which a patient s behaviour matches the prescriber s recommendations 1976 legendäre Kritik von Sackett und Haynes an der Compliance- Theorie Terminologiekriege? Treatment T t t compliance (also called adherence, concordance or persistence with treatment decisions (Grol/Wensing/Eccles 2004) ) Norbert Schmacke - Berlin 11.12.2009 Folie 2
Adherence The extent to which a person s behavior taking medication, following a diet and /or executing lifestyle changes, corresponds with agreed recommendations from a health care provider (Haynes and Rand zugleich Grundlage für WHO) Norbert Schmacke - Berlin 11.12.2009 Folie 3
Adherence-Forschung über 30 Jahre Dunbar J (1980) Adherence to medical advice: a review. International Journal of Mental Health, 9, 70-87 Zolnierek H et al (2009) Physician Communication and Patient Adherence to Treatment: A Meta-Analysis. Medical Care, 47, 826-834 Norbert Schmacke - Berlin 11.12.2009 Folie 4
Concordance The intention is to form a therapeutic alliance to help the patient make as informed a choice as possible about the diagnosis and treatment. Although this alliance is reciprocal, the most important determinations are made by the patient. We called this model "concordance." (Marinker 1997) Norbert Schmacke - Berlin 11.12.2009 Folie 5
Shared Decision Making Shared decision making is an approach where clinicians and patients t communicate together th when faced with the task of making decisions, where patients are supported to deliberate about the possible attributes and consequences of options, to arrive at informed preferences in making a determination about the best action, which respects patient autonomy, where this is desired, ethical and legal. (Elwyn, Strüngmann Forum 2009) Norbert Schmacke - Berlin 11.12.2009 Folie 6
Weder noch, sondern Schulung? Compliance and Adherence are Dysfunctional Concepts in Diabetes Care Anderson/ Funnell Plädoyer für Strategie des Self Management Expliziter Ansatz: evidenzbasierte, strukturierte und publizierte Schulungsprogramme (in begrenzter Zahl vorhanden) Norbert Schmacke - Berlin 11.12.2009 Folie 7
Norbert Schmacke - Berlin 11.12.2009 8
Patient-centered medicine 1. Exploring both the disease and the illness experience 2. Understanding the whole person 3. Finding common ground 4. Incorporating prevention and health promotion 5. Enhancing the patient-doctor relationship 6. Being realistic Stewart M et al Norbert Schmacke - Berlin 11.12.2009 Folie 9
Die andere Haltung (Stone et al 1998) Was hoffen Sie, das ich heute für Sie tun könnte? Sie haben ja schon Erfahrungen mit Ärzten was denken Sie, wie Sie am besten klar kommen? Ich finde es schwierig fortzufahren, wenn ich weiß, dass Sie eine andere Sicht der Situation haben als ich. Ich frage mich, ob wir so gut zusammen arbeiten wie es vielleicht möglich wäre. Gibt es irgend etwas an diesem Punkt, was ich tun könnte, damit wir besser zusammen arbeiten? Das muss sehr schwierig für Sie sein. Das tut mir leid. Es fällt Ihnen offenbar schwer, darüber zu sprechen. Kann ich es irgendwie für Sie einfacher machen? Ich habe jetzt eine Erklärung gefunden, was das Problem ist (Vorstellen der ärztlichen Diagnose). Wie passt das dazu, was Sie bisher darüber gedacht haben? Norbert Schmacke - Berlin 11.12.2009 Folie 10
Theorie und Praxis: work in progress Adherence:Stand der Forschung most interventions are eclectic in nature and not strictly representative of one theoretical mainstream. In addition, there are effective adherence interventions, e.g. technical solutions, without an explicit theoretical explanation of the operating mechanisms Van Dulmen et al 2008 Norbert Schmacke - Berlin 11.12.2009 Folie 11
Adherence to drug therapy and mortality: the healthy adherer good adherence was associated with lower mortality (odds ration 0.56, 95 % confidence interval 0.50-0.63). 0 Good adherence to placebo was associated with lower mortality (0.56, ci 0.43 to 0.74, as was good adherence to beneficial drug therapy (0.55, ci 0.49 to 0.62). Good adherence to harmful drug therapy was associated with increased mortality (2.90, ci 1.04 t0 8.11). supports the existence of the healthy adherer effect, whereby adherence to drug therapy may be a surrogate marker for overall healthy behaviour. Simpson et al 2006 Norbert Schmacke - Berlin 11.12.2009 Folie 12
Cochrane Database Syst Rev 2008 Interventions for enhancing adherence to prescribed medications For short-term drug treatments, counseling, written information and personal phone calls helped. For long-term treatments, no simple intervention, and only some complex ones, led to improvments in health outcomes. They included combinations of more convenient care, information, counseling, reminders, self-monitoring, reinforcement, family-therapy, psychological therapy, mailed communications, crisis interventions, manual telephone follow-up, and other forms of additional supervision or attention. Even with the most effective methods for long-term treatment, improvements in drug use or health were not large. Norbert Schmacke - Berlin 11.12.2009 Folie 13
Umgang g mit Unsicherheiten Respekt vor der Perspektive von PatientInnen Realisierung der Krankheitsarbeit der PatientInnen Erleichterung evidenzbasierter Entscheidungen Adherence Inhärente Asymmetrie der Beziehung Health Literacy (auf beiden Seiten) Kommunikative Kompetenzen Norbert Schmacke - Berlin 11.12.2009 14
Feine Beobachtungen Rezepte schreiben ist leicht, aber im übrigen sich mit den Leuten verständigen, ist schwer. Franz Kafka Ein Landarzt Leipzig 1918 Norbert Schmacke - Berlin 11.12.2009 Folie 15
Literatur Anderson RM, Funnell MM. Compliance and Adherence are Dysfunctional Concepts in Diabetes Care. The Diabetes Educator 2000; 26: 597-604 Bell S et al. Concordance is not synonymous with compliance or adherence. Br J Clin Pharmacol. 2007 November; 64(5): 710 711 Dulmen S van et al. Furthering patient adherence: A position paper of the international expert forum on patient adherence based on an internet forum discussion. BMC Health Services Research 2008, 8:47 Dunbar J, Adherence to medical advice: a review. International Journal of Mental Health, 1980; 9: 70-87 Grol R, Wensing M, Eclles M. Improving Patient Care. Butterworth Heineman, Oxford 2004 Härter M et al (Hrsg.) Gemeinsam entscheiden erfolgreich behandeln. Neue Wege für Ärzte und Patienten im Gesundheitswesen. Köln 2005 Haynes R B et al. Interventions ti for enhancing medications adherence. Cochrane Database Syst Rev 2008 Apr 16; (2): CD0000111 Marinker M. Writing prescriptions is easy. BMJ 1997; 314: 747 Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSD0). Concordance, adherence and compliance in medicine taking. December 2005 Sackett D:, Haynes RB. Compliance with therapeutic regimens. Baltimore, Johns Hopkins University Press, 1976 Schmacke N. Adherence: Therapietreue neu gedacht. Das Ende der Folgsamkeit. Gesundheit und Gesellschaft Spezial (5) 2009: 4-5 Simpson S H et al. A meta-analysis of the association between adherence to drug therapy and mortality. BMJ 2006; 333_15 (online 21 Jun 2006) Stewart t M et al. Patient-Centrered t t Medicine. i Transforming the Clinical i l Method. Radclliffe Medical Press 2003 (2nd edition) Stone M S et al. Meshing patient and physician goals. Strategic Medicine, January 1998. http://www.hsmgroup.com/info/compli/compli.html Zolnierek H et al. Physician Communication and Patient Adherence to Treatment: A Meta-Analysis. Medical Care 2009; 47_ 826-843 Norbert Schmacke - Berlin 11.12.2009 Folie 16
Vielen Dank für Ihre Aufmerksamkeit Prof. Norbert Schmacke www.akg.uni-bremen.de schmacke@uni-bremen.de Norbert Schmacke - Berlin 11.12.2009 Folie 17